Q&A: Physician impression trumps x-ray results

Q: I have been dealing with a denial issue where, because a chest x-ray did not show pneumonia and a repeat x-ray was not performed, the pneumonia was denied. In dehydrated or immunocompromised patient the chest x-ray may not initially show the pneumonia. I am now looking for supporting evidence to demonstrate pneumonia can be diagnosed without a positive chest x-ray, infiltrate, etc., does anyone know of a good reference for this?

A: “If the documentation indicates that the physician believes the patient has pneumonia and the documentation further illustrates that the physician is treating the patient for the pneumonia, that is all you should need to code for it,” says Tamara A. Hicks, RN, BSN, CCS, CCDS, ACM, manager, Care Coordination at Wake Forest University Baptist Medical Center in Winston Salem, NC.

“The situation is similar to that of sepsis. Coding Clinic for ICD-9-CM (Second Quarter, 2000,p. 5) says that you don’t have to have a positive blood culture to code sepsis. And according to AHIMA’s “Managing an Effective Query Process” release in 2008, queries should not be used to question a provider’s clinical judgment. So, as in this case, if the physician says the patient has pneumonia and everything else in the record supports his diagnosis despite the fact that the x-ray came back negative, the coder should be allowed to code for pneumonia. The AHIMA release states:

“Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Providers often make clinical diagnoses that may not appear to be consistent with test results.”